Carolina Orthopaedic and Neurosurgical Associates  Buy Up WLT CIP Standard 2 Tier- Health Insurance Plan Guide

Plan Overview

Basic Information

Detail	Information
Plan Type	Renewal
Group Name	Carolina Orthopaedic and Neurosurgical Associates
Legal Name	Carolina Orthopaedic and Neurosurgical Associates
Effective Date	01/01/2026
Master Group Number	65100
Subgroup(s)	65120
Benefit Plan(s)	Buy-up plan
ERISA Plan	Yes
Dental/Vision Benefits	Excepted (unbundled)
Fiscal Year Date (Plan Funding)	1/1-12/31
Benefits Applied per	Calendar Year
TPA	90 Degree Benefits
TPA Hours of Operation	8:00-5:00pm CST
Precertification Provider	CIGNA
Precertification Phone	888-832-0354
Number of Employees	174

Plan Status

Status Question	Answer
Does Plan Have Grandfather Status?	No
Is Plan considered a Qualified High Deductible Health Plan?	No

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Annual Deductibles and Cost Sharing

Deductibles (Per Calendar/Plan Year)

Coverage Level	Tier 1	Tier 2
Per Person	$1,750	$3,500
Per Family	$3,500	$7,000

Deductible Rules

Rule	Status
Do in and out of network deductibles cross-apply?	No
Cross-Apply Notes	SEPARATE
Does deductible apply to out-of-pocket maximum?	Tier 1: Yes / Tier 2: Yes
Do the amounts applied in the last 3 months carry over to the following year?	No
If yes, applies to:	N/A
If yes, does deductible carry over apply to OOP?	N/A

Coinsurance Rate (unless otherwise stated)

Tier	Plan Pays (After Deductible)	Member Pays
Tier 1	70%	30%
Tier 2	50%	50%

Annual Out-Of-Pocket Maximums

Coverage Level	Tier 1	Tier 2
Per Person	$7,900	$15,000
Per Family	$15,800	$30,000

Out-of-Pocket Rules

Rule	Status
Do in and out of network out of pocket maximums cross-apply?	No
Cross-Apply Notes	SEPARATE
Does 3-month Carry Over Out-of-Pocket benefit apply?	No
If yes, applies to:	N/A
Is out-of-pocket integrated with pharmacy?	Tier 1: Yes / Tier 2: Yes
Do copays apply to the out-of-pocket maximum?	Tier 1: Yes / Tier 2: Yes

Additional Benefit Rules

Rule	Status
Are all benefit maximums a combination of services received from either in- and out-of network providers or facilities?	Yes
Are Mental / Nervous Services covered?	Tier 1: Yes / Tier 2: Yes
Are Substance Abuse Services covered?	Tier 1: Yes / Tier 2: Yes
Comments	When covered all Mental Nervous and Substance Abuse benefits are paid as any other illness.

Additional Program Information

Program/Detail	Information
Specialty Drugs - New to Market waiting Period	6 months (both tiers)
How many levels of appeals apply before sending to IRO?	1 No 2 Yes
Teladoc Consult Fee	$0

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Network Configuration

Reference-Based Pricing (RBP) and Network Details

Detail	Tier 1	Tier 2
RBP?	No	Yes
If yes, % of Medicare	N/A%	SEE BELOW%
Benefit Level	65101	65100
Plan No	N/A	N/A
PPO Code	3002 (CIGNA)	0
Notes	For 90 Degree Benefits Use only	130% OF MEDICARE FOR PROFESSIONAL; 150% OF MEDICARE FOR FACILITIES

Additional Network Override

Tier	Group Code	PPO Code	Notes
Tier 1 Override	65101	11111	OVERRIDE TO PAY TIER 1

Value-Added Programs

Program	Available
A&G Editing/Bill Review	Yes
Patient Defender	Yes
Pace	Yes
CareConnect	Yes
Benchmark State	Utah

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ELIGIBILITY

Employee Information

Detail	Information
Number of employees	174
Special Note	Special COB rules may apply for employees with Medicare if employer has less than 100 EEs

FMLA and Leave Policies

Policy	Status
Standard FMLA	Yes
Do you allow Continuation of coverage for disability outside of FMLA?	NO
Do you allow Continuation of coverage for layoff?	NO
Do you allow Leave of absence that doesn't meet requirements of FMLA?	NO
Are benefits limited to full-time employees only?	No
If No, who else would qualify?	[Not specified]

Coverage Availability

Coverage For	Available
Domestic Partners	No
Common Law Spouse	No
Dependents	Yes
Adopted children	Yes
Foster children	Yes
Children under a legal guardianship	Yes
Grandchildren	Yes

Spouse and Reinstatement

Rule	Status
Is Spouse eligible for coverage if able to obtain coverage elsewhere?	Yes

Reinstatement of Coverage

Option	Selected
1. Employee is treated as a new hire	No
2. If no, waiting period is waived if rehired within ___ days	30 days

Stop Loss

Type	Information
Stop Loss – Specific	The following tracks to Specific MED/RX
Stop Loss – Aggregate	The following tracks to Aggregate MED/RX

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Continuity of Care

Detail	Status
Does the plan offer continuity of care benefits?	Yes
Notes	For persons under care for a serious illness or pregnancy, network benefits are available for a limited period if the primary care physician leaves the network.
Comments	Standard 90 days

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Precertification / Notification

Precertification Details

Detail	Information
Precertification / Notification provided by	CIGNA
Precertification Phone Number	888-832-0354
Applicable Services requiring Precertification	See Precertification Pages
Allow retroactive Precertification?	Yes
If no, services requiring precertification will be denied if not on file	N/A
Will a penalty apply for obtaining a Post-Service Precertification	No
Amount	N/A
Precert required for Medicare Primary?	No
Precert required if Other Coverage Primary?	No

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OFFICE VISITS AND OUTPATIENT SERVICES

Medical Office Visit

Coverage Code: AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	No	Yes
Does co-pay apply?	Yes	No
If yes co-pay amount	$30	$
How is copay applied?	PER PROVIDER PER DAY	N/A
Paid by plan	100%	50%
Is there a different co-pay amount for Specialists?	Yes	No
If yes, co-pay amount	$60	$

Office Surgery (Includes related anesthesia services)

Coverage Code: AF, AFQ, AFS, OPM, OPMS, SF, SFS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	No	Yes
Does co-pay apply?	Yes	No
If yes co-pay amount	$30	$
How is copay applied?	PER PROVIDER PER DAY	N/A
Paid by plan?	100%	50%
Is there a different co-pay amount for Specialists?	Yes	No
If yes, co-pay amount	$60	$

Therapeutic Injections (Office)

Coverage Code: INJ, INJS, MINJ, ZMIN

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	No	Yes
Does co-pay apply?	Yes	No
If yes co-pay amount	$30	$
How is copay applied?	PER PROVIDER PER DAY	N/A
Paid by plan	100%	50%
Is there a different co-pay amount for Specialists?	Yes	No
If yes, co-pay amount	$60	$

Allergy Injections and Serum

Coverage Code: ALI, ALIS, ALS, ALSS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Is there a different co-pay amount for Specialists?	No	No
If yes, co-pay amount	$	$

Allergy Testing

Coverage Code: ALT, ALTS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	No	Yes
Does co-pay apply?	Yes	No
If yes co-pay amount	$30	$
How is copay applied?	PER PROVIDER PER DAY	N/A
Paid by plan	100%	50%
Is there a different co-pay amount for Specialists?	Yes	No
If yes, co-pay amount	$60	$

Office charges for X-ray & Professional Component

Coverage Code: XRDR, XRDS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does this include High Cost Imaging such as MRI's, CT, PET, etc.?	No	No
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Is there a different co-pay amount for Specialists?	No	No
If yes, co-pay amount	$	$

Office charges for Laboratory & Professional Component

Coverage Code: LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Is there a different co-pay amount for Specialists?	No	No
If yes, co-pay amount	$	$

Office charges Diagnostic Testing

Coverage Code: ODX, ODXS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Is there a different co-pay amount for Specialists?	No	No
If yes, co-pay amount	$	$

All Other Office Related Services

Coverage Code: HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Is there a different co-pay amount for Specialists?	No	No
If yes, co-pay amount	$	$

Independent Laboratory & Professional Component

Coverage Code: LAB

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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DIAGNOSTIC SERVICES

Lab/Xray/Diagnostic Imaging – Including Ultrasound-Outpatient Physician

Coverage Code: PRF

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Lab/Xray/Diagnostic Imaging – Including Ultrasound-Outpatient Testing and/or Facility fee

Coverage Code: CUS, HLAB, HXL, HXR, MXL, OPDX, OUSS, SMXL, SXL, US, XRAY

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Major Diagnostic Procedures - Physician

(Including, but not limited to, MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, and Bone Scans, facility/professional expenses, all Outpatient and office places of service)

Coverage Code: PRF

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Major Diagnostic Procedures - Testing and/or Facility fee

(Including, but not limited to, MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, and Bone Scans, facility/professional expenses, all Outpatient and office places of service)

Coverage Code: BONE, CAT, CST, HCAT, MRIO, MRIS, MYEL, NUC, NUCO, NUCS, OBON, OBOS, OCAT, OCSS, OCST, OCUS, OMRI, OMYE, OMYS, OPES, OPET, OSPC, OSPS, PET, SCAT, SPCT

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Sleep Studies

Coverage Code: OSLP, SLPS

Detail	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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ALTERNATIVE AND SPECIALTY SERVICES

Acupuncture Services

Coverage Code: AP, APS

Detail	Tier 1	Tier 2
Covered Service?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%
Maximum visits	[blank]	[blank]
Maximum benefit	$	$

Ambulance and other medically appropriate transport (ground and air)

Coverage Code: AMB, AMBR, AR

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	70%
Include facility to facility when medically necessary?	Yes	Yes
Comments	Tier 2 applies tier 1 ded/oop

Chiropractic Services

Coverage Code: CH, CHX

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum visits/benefit	No benefit maximum No / Calendar year No / Plan year No / Other Yes
Maximum	$500 per calendar year

Durable Medical Equipment (includes DME supplies)

Coverage Code: BRA, DIEQ, DME, DMS, DTE, MMS

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Are Insulin pumps considered Durable Medical Equipment?	Yes
Does this include the insulin pump supplies?	Yes
Do you cover cost of repairs not due to misuse?	Yes
Do you cover cost of replacements if equipment is no longer functioning, is outside the warranty period and the defect is unable to be repaired?	Yes
Do you cover batteries?	Yes
Do you cover sales tax and shipping charges?	Yes
Is there a rental maximum up to purchase price of equipment?	Yes

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EXTENDED CARE AND HOME HEALTH

Extended Care Facility Benefits (skilled nursing, subacute facility)

Coverage Code: SNF

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum days/visits	No day maximum No / Calendar year Yes / Plan year No / Other No
Maximum	60 days per calendar year

Home Health Care Benefits

Coverage Code: HHC, HHS, PHC, PHS

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum days/visits	No day maximum No / Calendar year Yes / Plan year No / Other No
Maximum	60 visits per calendar year

Hospice Care Benefits

Coverage Code: HO, OHO

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum days/visits	No day maximum Yes / Calendar year No / Plan year No / Other No
Allow Custodial / Respite Care	Yes
If yes, should this be included in the Hospice benefit?	Yes N/A No

Bereavement Counseling

Coverage Code: HBC, HFC

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Include Bereavement counseling in Hospice benefit?	Yes	Yes
If yes, maximum visits for Bereavement counseling	No day maximum No / Calendar year No / Plan year No / Other Yes
Other Explanation	Services must be furnished within 6 months of death
Paid by plan	70%	50%

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HOSPITAL SERVICES

Emergency Room Hospital Facility Services

Coverage Code: ER, MNO, NER, SMOF, SNO

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Do you want all emergency services paid in network?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
If admitted within 24 hours do you waive co-pay	Yes	Yes
How is copay applied?	N/A	N/A
Paid by plan	70%	70%
Comments		Tier 2 applies Tier 1 ded/oop

Emergency Room Hospital Professional Services

Coverage Code: ERD, MERD, NERD, SAER, SMER

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Do you want all emergency services paid in network?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	70%
Comments		Tier 2 applies Tier 1 ded/oop

Inpatient Facility Services

Coverage Code: BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Is Notification penalty waived for Emergency admissions?	Yes	Yes
If admitted through the ER, is the ER copay waived?	Yes	Yes
Reduce to semi-private room rate if available in the hospital?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Ancillary (All Other Inpatient) Services

Coverage Code: DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Infusion Therapy

Coverage Code: IVIN

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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SURGICAL SERVICES

Expenses related to Surgery

Second Surgical Opinion Coverage Code: SV, SVS

Comments: Paid same as any other illness

Anesthesia

Coverage Code: AI, AIQ, AO, AOQ, MNA, SMA

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Surgeon / Assistant Surgeon / Co-Surgeon

Coverage Code: CIRC, SI, SO, STER, TI, TO

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Assistant Surgeon bills will be limited to 25% of the Usual and Customary fee for type of procedure performed	Yes	Yes

Outpatient Hospital Surgery and Ambulatory Surgical Center

Coverage Code: ASF, OHS

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan after co-pay and deductible	70%	50%

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MATERNITY AND NEWBORN SERVICES

Maternity Surgery (includes physician attendance)

Coverage Code: MAT, MATD, MATO

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Routine Newborn Care

Coverage Code: CIRC, HNS, WC

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Outpatient Hospital Services – Unless otherwise specified

Coverage Code: CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Outpatient Physician Services – Unless otherwise specified

Coverage Code: DIED, HBP, PM

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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OTHER OUTPATIENT SERVICES

Dialysis

Coverage Code: DI, HDI

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Urgent Care Services

Coverage Code: URG

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	No	Yes
Does co-pay apply?	Yes	No
If yes co-pay amount	$60	$
How is copay applied?	PER PROVIDER PER DAY	N/A
Include all related services? (If no, see comments below)	Yes	Yes
Paid by plan	100%	50%

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OLOGIST BENEFITS (REAP)

Hospitalists, Radiology, Emergency Room Physician, Anesthesiology & Pathology

Rule	Status
Are services for Hospitalists, Radiology, Pathology and Anesthesiology providers paid as in-network when performed at a participating facility?	Yes
Are services for Emergency Room Physicians paid as In-Network?	Yes
Are charges paid in network if referred by a participating physician?	Yes
Are services performed outside of the service area paid as In-Network? If yes, how many miles from the participant's residence?	Yes / 100 miles
Are services, unable to be provided by a network provider, paid as In-Network?	Yes
Is the Network level of benefits payable when a participant receives emergency care either out of area or at non-network hospital for an accidental bodily injury or emergency?	Yes

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INFERTILITY TREATMENT SERVICES

Coverage Code: INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT

Detail	Tier 1	Tier 2
Covered Service?	No	No

Type of Service Coverage

Type of Service	Covered?
Diagnostic only (to determine diagnosis)	No (Tier 1) / No (Tier 2)
Genetic testing to diagnose infertility	No (Tier 1) / No (Tier 2)
Diagnostic & other services	No (Tier 1) / No (Tier 2)
Fertility Test	No (Tier 1) / No (Tier 2)
Tests and exams done to prepare for induced conception	No (Tier 1) / No (Tier 2)
Surgical reversal of sterilized state which was the result of a previous surgery	No (Tier 1) / No (Tier 2)
Sperm enhancement procedures	No (Tier 1) / No (Tier 2)
Direct attempts to cause pregnancy including	No (Tier 1) / No (Tier 2)
Hormone or therapy drugs	No (Tier 1) / No (Tier 2)
Artificial Insemination	No (Tier 1) / No (Tier 2)
Invitro Fertilization	No (Tier 1) / No (Tier 2)
Gamete Intrafallopian Transfer (GIT)	No (Tier 1) / No (Tier 2)
Zygote Intrafallopian Transfer (ZIFT)	No (Tier 1) / No (Tier 2)
Embryo Transfer	No (Tier 1) / No (Tier 2)
Freezing or storage of embryo, eggs or semen	No (Tier 1) / No (Tier 2)

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SPECIALTY TREATMENT SERVICES

Chemotherapy / Radiation Therapy Professional

Coverage Code: CT, HCT, HRT, RT

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Chemotherapy / Radiation Therapy Facility

Coverage Code: CT, HCT, HRT, RT

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Hearing Aids

Coverage Code: HA, HA2, HARC

Detail	Tier 1	Tier 2
Covered Service?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%
Maximum benefit	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other No

Orthotics

Coverage Code: DS, OR, ORH, ORI, ORS

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Allow custom-molded foot orthotics?	Yes	Yes
Allow non-custom molded shoe inserts?	Yes	Yes
Allow diabetic shoes?	Yes	Yes
If yes, limits?	1 pair per calendar year up to $500

Prosthetics

Coverage Code: PRO

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Initial purchase, fitting, repair and replacement covered?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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PREGNANCY / MATERNITY BENEFITS – MISC

Coverage Code: See appropriate benefit section

Pregnancy Benefits

Question	Answer
Are services performed in a Physician's office paid according to the benefits outlined in the Medical Office Visit section of this form?	Yes
Are services performed in a Hospital paid according to the benefits outlined in the Hospital section?	Yes
Allow dependent daughter pregnancies?	Yes (If no, PPACA required services are covered)
Allow outpatient birthing centers?	Yes
Allow home deliveries?	Yes
Allow all elective abortions?	No
Do you cover elective abortions when pregnancy is the result of a crime (rape or incest)? Must be compliant with applicable state law	Yes
Do you cover elective abortions when the life of mother is in danger? Must be compliant with applicable state law	Yes
Are abortions covered for	All females covered under the plan No / Employee/Spouse only No
Allow sterilization?	Yes

Newborns

Question	Answer
Apply normal plan benefits	No
Process under mother	No
Newborn dependents	Must be enrolled on the plan within 31 days. No / Automatic 31-days coverage, must enroll thereafter No / Automatic 31-day coverage only if EE already has Dependent coverage, must enroll thereafter. Yes

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PREVENTIVE CARE SERVICES FOR ACA COVERED SERVICES

Coverage Code: AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX

Non-Grandfathered Plan Information

The plan will follow the US Preventive Services Task Force recommendations, found at http://www.uspreventiveservicestaskforce.org/BrowseRec/Index

Preventive services are covered without cost sharing. This generally applies only when services are rendered by a network provider.

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	100%	%
Details	Not covered if Out-of-Network

Are there any additional services covered under a separate Wellness Benefit not included in the US Preventive Services Task Force recommendations? No

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ROUTINE/WELLNESS OUTSIDE OF ACA

Routine Physical Exam

Coverage Code: HWC, WCB, WCBS, WLB, WLBS

Detail	Tier 1	Tier 2
Are there any routine physical exams not already required to be covered by the ACA, covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Immunization

Coverage Code: IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH

Detail	Tier 1	Tier 2
Are there any Immunizations, not already required to be covered by the ACA, covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%
List any non-covered immunizations	[blank]

Routine Diagnostic Tests, Labs, X-rays

Coverage Code: HWL, WLAB, WXL, WXR

Detail	Tier 1	Tier 2
Are there any Routine Diagnostic Tests, Labs, X-rays, not already required to be covered by the ACA, covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Routine Mammogram

Coverage Code: MAM, MAM2, OMAM, OMAS, OMA2, OM2S

Detail	Tier 1	Tier 2
Are there any Routine Mammograms, not already required to be covered by the ACA, covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Routine Pap Smear / Test and Pelvic Exam

Coverage Code: PAP, PAPR, PAPS

Detail	Tier 1	Tier 2
Are there any additional circumstances for Routine Pap Smear / Test and Pelvic exams to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Routine Fecal Blood Culture

Coverage Code: WLB

Detail	Tier 1	Tier 2
Are there any additional circumstances for Routine Fecal Blood Culture to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Routine PSA Test and Prostate Exam

Coverage Code: PS, PSS

Detail	Tier 1	Tier 2
Cover Routine PSA Test and Prostate Exam as routine?	Yes	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	100%	%
Details	Out of network is not covered

Routine Colonoscopy, Sigmoidoscopy and similar Preventative routine procedures

Coverage Code: OCOL, OCOS, WLAB, WLB, WXL, WXLS

Detail	Tier 1	Tier 2
Are there any additional circumstances for Routine Colonoscopy, Sigmoidoscopy or similar Preventative routine procedures to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Contraceptive Management

Coverage Code: BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT

Detail	Tier 1	Tier 2
Are there any additional circumstances for contraceptive management to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Routine Hearing Exam

Coverage Code: RHE

Detail	Tier 1	Tier 2
Are there any additional circumstances for Routine Hearing Exams to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

Nutritional Counseling

Coverage Code: WCBS

Detail	Tier 1	Tier 2
Are there any additional circumstances for Routine Behavioral \ Nutritional Counseling to be covered as wellness?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
Paid by plan	%	%

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VISION CARE BENEFITS

Coverage Code: REE, VEX

Vision Plan Information

Question	Answer
Is there a separate benefit allowed for Vision care?	No
If no, is there another vendor?	Yes
Vendor Name	VSP
Phone Number	[See member materials]
Medical related Eye Exams and glaucoma testing covered under medical?	Yes
Glaucoma and cataracts covered under Medical?	Yes
Routine eye exams covered under medical?	No
If yes, are routine eye exams included in the Routine benefits maximum or in the Vision care benefits?	Routine benefit No / Vision care benefit No

Routine Eye Refraction

Detail	Tier 1	Tier 2
Is there a benefit for routine eye refractions?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%

Other Vision Care Services

Coverage Code: HW, PHW, VANA, VBL, VCD, VCL, VFR, VINE, VLB, VLS, VLT, VSL, VTL, VTNT

Are any of these covered under Medical Plan?

Service	Covered	Maximum
Lenses - Single Vision	No	$
Lenses - Bifocal	No	$
Lenses - Trifocal	No	$
Lenses - Lenticular	No	$
Lenses - Progressive Lens	No	$
Lenses - Lens Coating	No	$
Frames	No	$
Contacts	No	$
Safety Lenses and Frames	No	$
Sunglasses or subnormal vision aids	No	$

Additional Vision Services

Service	Tier 1	Tier 2
Eye Surgeries used to improve/correct eyesight for refractive disorders (i.e. Lasik surgery, radial keratotomy, etc.)	No	No
Fitting or dispensing of non-prescription glasses or vision devices whether or not prescribed by a physician	No	No
Vision therapy services including orthoptics?	No	No
Correction of visual acuity or refractive errors	No	No
Aniseikonia (Each eye sees an object differently)	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%

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ORAL SURGERY BENEFITS PAID UNDER MEDICAL

Coverage Code: See applicable benefit section

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes

Allow coverage for the following including all related services under medical?

Service	Covered
Excision of partially or completely impacted teeth	Yes No No No See comments
Excision of tumors and cysts of the jaw, cheeks, lips, tongue, roof and floor of the mouth when such conditions require pathological exams	Yes
Surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth.	Yes
Reduction of fractures & dislocations of the jaw	Yes
External incision and drainage of cellulitis	Yes
Incision of accessory sinuses, salivary glands or ducts	Yes
Excision of exostosis of jaws and hard palate	Yes
Frenectomy – (the cutting of the tissue in the midline of the tongue)	Yes
Gingival mucosal surgery (gingivectomy, osseous, periodontal surgery and grafting) to treat gingivitis or periodontitis	Yes
Apicoectomy – (the excision of the tooth root without the extraction of the entire tooth)	Yes
Root canal therapy if performed in conjunction with an Apicoetomy	Yes
Alveolectomy (leveling of structures supporting teeth for the purpose of fitting dentures). Not payable if performed in conjunction with routine extraction of natural teeth.	Yes

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OTHER DENTAL SERVICES

Coverage Code: See applicable benefit section

Service	Tier 1	Tier 2
Allow Dental Implants?	No	No
Allow Anesthesia, X-ray, and Lab for medically appropriate hospital services?	Yes	Yes
Allow coverage for any other dental services under the medical plan?	No	No

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TEMPOROMANDIBULAR JOINT DISORDER BENEFITS

Coverage Code: TMJ, TMJO, TMJS

Detail	Tier 1	Tier 2
Covered service?	No	No

Covered Services

Type	Covered
All (surgery, appliances, adjustments)	No (Tier 1) / No (Tier 2)
Diagnostic only – to determine diagnosis	No (Tier 1) / No (Tier 2)
Non surgical treatment	No (Tier 1) / No (Tier 2)
Surgery only	No (Tier 1) / No (Tier 2)

Detail	Information
Does deductible apply?	No
Does co-pay apply?	No
If yes co-pay amount	$
How is copay applied?	N/A
Paid by plan	%
Maximum benefit per	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other No
Maximum lifetime amount	$
What services does the maximum apply to	Surgical No / Non – Surgical No / Other No List

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THERAPY SERVICES

Physical Therapy (Outpatient treatment)

Coverage Code: DPT, HPT, PT

Detail	Tier 1	Tier 2
Are Physical therapy and Occupational therapy a combined benefit?	No
Is Aquatic therapy performed in conjunction with PT covered?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum benefit per	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other Yes
Other Explanation	36 VISITS
Comments	Includes massage therapy performed by a covered provider.

Occupational Therapy (Outpatient treatment)

Coverage Code: HOT, OT

Detail	Tier 1	Tier 2
Are Physical therapy and Occupational therapy a combined benefit?	No
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum benefit per	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other Yes
Other Explanation	36 VISITS
Comments	Includes massage therapy performed by a covered provider.

Speech Therapy

Coverage Code: HST, ST

Detail	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum benefit per	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other Yes
Other Explanation	20 VISITS

Other Outpatient Rehabilitative and Habilitative services

(ABA therapy, Cognitive Rehab, Cardiac rehab, Pulmonary rehab)

Coverage Code: ABA, ABAH, COGR, CR, PRHB

Detail	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	50%
Maximum benefit per	No benefit maximum Yes / Calendar year No / Plan year No / Lifetime No / Other No

Massage Therapy (Performed by a massage therapist)

Coverage Code: MT

Detail	Tier 1	Tier 2
Covered Service?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%
Maximum benefit per	No benefit maximum No / Calendar year No / Plan year No / Lifetime No / Other No
Comments	Massage therapy services are covered when a medical diagnosis exists and services are provided by a Physical Therapist, Occupational Therapist, or Physician.

Wigs, for cancer treatment or a medically appropriate condition

Coverage Code: WIG

Detail	Tier 1	Tier 2
Covered Service?	No	No
Does deductible apply?	No	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	%	%
Maximum benefit per	No maximum No / Calendar year No / Plan year No / # No / # No

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TRANSPLANT SERVICES

Transplant Policy

Detail	Tier 1	Tier 2
Is there a separate transplant policy in place?	No	No
If yes, Transplant services provided by	[blank]
Phone	[blank]
Covered when donor is covered under the plan but recipient is not?	Yes	Yes

Transplant Facility Benefits - Recipient

Coverage Code: TRN

Detail	Tier 1	Tier 2
Covered Service?	Yes	No
Does deductible apply?	Yes	No
Does co-pay apply?	No	No
If yes co-pay amount	$	$
How is copay applied?	N/A	N/A
Paid by plan	70%	%

Facility - Travel and Housing - Recipient

Coverage Code: TRL, TRNT

Service	Covered
Covered Service?	No
Airfare	No (Tier 1) / No (Tier 2)
Meals	No (Tier 1) / No (Tier 2)
Tolls	No (Tier 1) / No (Tier 2)
Parking Fees	No (Tier 1) / No (Tier 2)
Apartment Rental	No (Tier 1) / No (Tier 2)
Hotel / Motel	No (Tier 1) / No (Tier 2)
Relocation Fees	No (Tier 1) / No (Tier 2)
Taxes	No (Tier 1) / No (Tier 2)
Do you allow travel expenses?	No (Tier 1) / No (Tier 2)

Facility Benefits - Living Donor

Coverage Code: TRN

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes

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MENTAL NERVOUS/SUBSTANCE ABUSE SERVICES

Mental Nervous/Substance Abuse Residential Treatment Center

Coverage Code: MRES, SRES

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

Mental Nervous/Substance Abuse Outpatient Facility Treatment -All (PHP, DT, IOP, etc.)

Coverage Code: DT, SDT, SMDT

Detail	Tier 1	Tier 2
Covered Service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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ALL OTHER COVERED SERVICES (NOT OTHERWISE SPECIFIED)

Coverage Code: [blank]

Detail	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
How is copay applied?	N/A	N/A
Paid by plan	70%	50%

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PRESCRIPTION DRUGS

Coverage Code: PCS (Invoice only)

Drug Plan Information

Detail	Information
Are Prescription Drugs covered under the Medical plan	Drug plan Yes / Not covered No
6-month waiting period for new to market specialty drugs	Yes
If Drug Plan Name of RX Vendor	TrueScripts
Does deductible apply?	Yes (Tier 1) / Yes (Tier 2)
Does co-pay apply?	Yes (Tier 1) / Yes (Tier 2)
If yes, apply deductible after co-pay?	No NA No (Tier 1) / No NA No (Tier 2)

Copay Structure

Drug Type	Days Supply	Copay
TIER 1	1-30	$15
TIER 1	31-90	$25
TIER 2	1-30	$40
TIER 2	31-90	$90
TIER 3	1-30	$70
TIER 3	31-90	$175
SPECIALTY TIER 1	1-30	$125
SPECIALTY TIER 2	1-30	20% TO $550 MAXIMUM
SPECIALTY TIER 3	1-30	20% TO $2000 MAXIMUM
SPECIALTY TIER 4	1-30	20%
SPECIALTY TIER 5	1-30	50%

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SPECIALTY PHARMACY INJECTABLE DRUGS

Coverage Code: SPD

Question	Answer
Are benefits for Injectable drugs covered under the medical plan and will they be paid the same as other medical office services?	Yes
Comments	Medications and supplies related to the administration of injectable prescription medication may be covered under the Medical or Pharmacy benefits but not both.

How are the following items covered?

Item	Medical Plan	Drug Plan	Not Covered
Diabetic Supplies	Tier 1: Yes / Tier 2: Yes
Insulin	Tier 1: Yes / Tier 2: Yes
Growth Hormones	Tier 1: Yes / Tier 2: Yes
Take home medications	Tier 1: Yes / Tier 2: Yes

How are the following Contraceptive Products covered?

Item	Medical Plan	Drug Plan	Not Covered
Contraceptive patches, oral tablets, or self-insertable vaginal devices containing contraceptives hormones (i.e. Nuva ring)		Tier 1: Yes / Tier 2: Yes
Contraceptive Injections (such as Depo-Provera)	Tier 1: Yes / Tier 2: Yes
Contraceptives administered in the Dr. Office (i.e. IUDs, implants)	Tier 1: Yes / Tier 2: Yes

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MISCELLANEOUS COVERAGE

Excluded and Covered Services

Service	Coverage Code	Excluded	Covered
Abortion - elective	ABO	Yes	No
Alternative/Complimentary Treatment	INEL	Yes	No
- Holistic or homeopathic medicine
- Hypnosis
- Other alternative treatment that is not accepted medical practice as determined by the Plan.
Treatment for Acquired Brain Injury	See appropriate benefit section		Yes Include State Mandated benefits OR; Payable same as any other illness
Autism Services required per MHPAEA	DEVD		Yes
If yes, Applied Behavior Analysis	ABA, ABAH		Yes
Biofeedback	BFF		Yes
Blood Pressure Cuffs/Monitors	INEL	Yes	No
Botox (medically necessary)	BOT		Yes
If covered, covered through			Medical Yes PBM No Both No
Breast Reductions if medically appropriate	See appropriate benefit section		Yes
Counseling – Marriage	INEL	Yes	No
Developmental Delays	DEVD		Yes
- Occupational Therapy
- Physical Therapy
- Speech Therapy
- Medical Charges
Treatment of bunions, corns, calluses and toenails unless medically necessary	INEL	Yes	No
Gender Affirming Care	INEL	Yes	No
Genetic Counseling or Testing based on Medical Appropriateness or family history (ACA mandated genetic testing is covered)	GEN		Yes
Gene Therapy-Medical and/or Prescription drug charges (a technique that uses a gene(s) to treat, prevent or cure a disease or medical disorder)	GENE		Yes
Orphan drugs-Medical and/or Prescription drug charges (An orphan drug is a drug for a rare disease or condition.)	ORPH		Yes
Implantable hearing devices (i.e., cochlear, soundtec)	CIRH, COCH		Yes
Learning Disability	DEVD	Yes	No
Enteral and Parenteral Support - (administered through a tube as the sole source of nutrition for the Covered Person)	MMS		Yes
Oral Nutrition Therapy if medically necessary	MMS		Yes
Supplies including feeding tubes, pumps, bags and products (administered through a tube as the sole source of nutrition for the Covered Person)	MMS		Yes
Orthognathic, Prognathic and Maxillofacial Surgery (Unless covered under TMJ benefit or Reconstructive Surgery)	See appropriate benefit section if covered	Yes	No
Panniculectomy/Abdominoplasty	INEL	Yes	No
Sales Tax, shipping and handling	INEL	Yes	No
Complications from a non covered service	INEL	Yes	No

Sexual Function

Service	Status
(any medications, oral or other, used to increase sexual function or satisfaction or penile pumps and erectaid devices)
- Diagnostic	See appropriate benefit section
- Non Surgical	See appropriate benefit section
- Surgical	See appropriate benefit section
- Prescription Drugs	See appropriate benefit section

Sleep Disorders (if medically appropriate)

Service	Coverage Code	Covered
Sleep Studies	OSLP, SLMS, SLDM, SLPS	Yes

Telemedicine

Service	Coverage Code	Status
Patient to Physician	TELM, TELS	Yes
Physician to Physician	INEL	Yes
Teladoc (separate benefit from medical)	TELA, TELB	Yes

Smoking Cessation Drugs

Detail	Status
If covered
- Paid under medical benefit	SMK / No
- Paid under Prescription Drug benefit	No

Weight Control (Morbid Obesity)

Service	Coverage Code	Status
Covered Service?	BAR, BARS, OBE
If covered
- Definition of body mass index (or)		No
- 100 pounds over body weight		No
- Bariatric Therapy		No
- Gastric or intestinal bypass		No
- Stomach stapling		No
- Prescription medication needed for weight loss		No
- Physician supervised weight loss programs		No
- Diet Supplements		No

Injuries

Type	Status
Incurred while legally intoxicated	No Excluded
Illegal Drugs or Medicines (illness or Injury resulting from that Covered Individual's voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen, or narcotic not administered on the advice of a Physician.)	No Excluded

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GENERAL ITEMS

Dependent and Payment Information

Detail	Information
Dependent Age Limitations	26
Percentile of Usual and Customary used (Out of Network)	80th (Standard) Yes / 85th No / 90th No / 95th No
% of Medicare	130/150% Yes / Other No

Provider Coverage Under Medical Plan

Provider Type	For Medical	For Mental Health Treatment
CNM – Certified Nurse Midwife	Yes	No
Chiropractor	Yes	No
Licensed Professional Counselor	Yes	No
Certified addiction counselor (for substance abuse)	Yes	No
PSY.D. - Therapist with a PhD or master's degree in psychiatry or related field	No	Yes
State licensed psychologist	No	Yes
Licensed or certified Social Worker	Yes	No
MSW - Masters in Social Work	Yes	No
Massage Therapist	No	No

Timely Filing Period

Option	Selected
12 Months	Yes
15 Months	No
18 Months	No
24 Months	No
Other	No

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COORDINATION OF BENEFITS

COB Rules

Question	Answer
Is COB the same for Medicare eligible employees?	Yes
If no, what COB provision should be used for Medicare eligible employees?	[N/A]
Medicare – If plan is not primary and a covered person has Part A, but has not elected Part B, will this plan reduce the benefits as if Part B was elected?	Yes
Birthday Rule or Gender Rule	Birthday Yes
Do you question primary carrier for their Rule?	Yes

Coordination of Benefits Savings

Establishes how the plan will process savings for members with Other Insurance.

Options:

• 0 - Accumulated COB savings are applied toward satisfying the deductible and reducing the copayment on claims (both the current COB claim and future claims) until accumulated savings are used up. COB savings accumulate for each plan participant in a "COB bank" in the claimant's name.
• 1 - COB savings are applied toward satisfying the claimant's deductible and reducing the copayment portion of only the current claim.
• 2 - Carve Out COB – COB saving is not used to satisfy a member's deductible or reduce the copayment on the current or future claims. Saving accumulate in the plan's name and reduce the plan's liability only.

COB Payment Code

Options:

• 0 – COB Savings are applied to the entire claimant's incurred charges, even if the charges are not eligible under the plan. For example, COB savings are used to pay for services denied as cosmetic.
• 1 – COB savings are applied only to charges that are eligible under the plan.
• 2 – COB savings are applied only to charges that are eligible under the plan, BUT savings will not be applied toward the annual accumulators.
• 3 – The COB Savings code is not considered, and savings will not be generated.
• 9 – COB processing will be ignored for the group, regardless of any COB amounts that may be entered on the claim.

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DOCUMENT COMPLETION INFORMATION

Detail	Information
This Form Completed by	Susan Green
Title	Plan Build
Date Completed	12/26/2025

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CUSTOMER APPROVAL SECTION

Note: Your approval of this installation document is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.

Any changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.

Customer Comments (if any): [blank]

Date: [blank]

Signature of Customer: (An electronic signature will be accepted)

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PLAN MODIFICATIONS SECTION

Group Name: [blank]

Effective Date: [blank]

Group Number: [blank]

The Install Plan Document is hereby modified as follows: [blank]

This Form Completed by: ________@ 90 Degree Benefits

Date Completed: [blank]

CUSTOMER APPROVAL SECTION (Modifications)

Note: Your approval of these modifications is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.

Any further changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.

Customer Comments (if any): [blank]

Date: [blank]

Signature of Customer: (An electronic signature will be accepted)

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PRECERTIFICATION LISTING

CIGNA PRE-CERTIFICATION LISTING

[Reference to separate precertification document - not included in this install document]

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Important Contact Information

Key Phone Numbers and Resources

Contact	Information
90 Degree Benefits (TPA)	Hours: 8:00 AM - 5:00 PM CST
CIGNA Precertification	Phone: 888-832-0354
TrueScripts (Pharmacy)	Contact information on member ID card
VSP (Vision)	Contact information in member materials
Teladoc	$0 consult fee - Contact information in member materials

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Key Plan Features Summary

Critical Information for Members

1. Two-Tier System: This plan offers two levels of coverage with different cost-sharing arrangements
2. Separate Accumulators: In-network and out-of-network deductibles and out-of-pocket maximums are SEPARATE and do not cross-apply
3. Integrated Pharmacy: Prescription drug costs count toward medical out-of-pocket maximum
4. Emergency Services: Tier 2 members receive Tier 1 benefits (70% coinsurance and Tier 1 deductible/OOP) for emergency room and ambulance services
5. REAP Providers: Certain specialists may be covered at in-network rates under specific circumstances
6. Precertification Required: Many services require precertification through CIGNA - failure to obtain precertification may result in denial
7. Preventive Care: 100% covered in Tier 1 when using network providers with no deductible or copay
8. Mental Health Parity: Mental health and substance abuse services covered as any other illness
9. No Carryover: Last 3 months of deductible DO NOT carry over to the following year
10. Timely Filing: Claims must be submitted within 12 months of service date

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Frequently Used Coverage Codes Quick Reference

Office Services

• Office Visit: AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV
• Office Surgery: AF, AFQ, AFS, OPM, OPMS, SF, SFS
• Injections: INJ, INJS, MINJ, ZMIN
• Allergy Injections: ALI, ALIS, ALS, ALSS
• Allergy Testing: ALT, ALTS

Diagnostic Services

• Laboratory: LAB, LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX
• X-Ray: XRDR, XRDS, XRAY
• Major Diagnostic: BONE, CAT, CST, MRIO, MRIS, PET, etc.
• Sleep Studies: OSLP, SLPS

Hospital Services

• Emergency Room Facility: ER, MNO, NER, SMOF, SNO
• Emergency Room Professional: ERD, MERD, NERD, SAER, SMER
• Inpatient: BC, HM, HNS, ICU, IMC, MHM, MRB, RB
• Ambulance: AMB, AMBR, AR

Surgery

• Anesthesia: AI, AIQ, AO, AOQ, MNA, SMA
• Surgeon: CIRC, SI, SO, STER, TI, TO
• Outpatient Surgery: ASF, OHS

Therapy

• Physical Therapy: DPT, HPT, PT
• Occupational Therapy: HOT, OT
• Speech Therapy: HST, ST

Other Services

• Urgent Care: URG
• Chiropractic: CH, CHX
• DME: BRA, DIEQ, DME, DMS, DTE, MMS
• Preventive: AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV

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This knowledge base article contains the complete details from the Carolina Orthopaedic and Neurosurgical Associates health plan document effective January 1, 2026. For official plan documents or questions, please contact 90 Degree Benefits during business hours (8:00 AM - 5:00 PM CST).

Document prepared by: Susan Green, Plan Build - December 26, 2025 Last updated: January 30, 2019 (Template)